14. SHIP TO
ORDER FOR SUPPLIES OR SERVICES
PAGE 1 OF
1. CONTRACT/PURCH ORDER/AGREEMENT NO. 2. DELIVERY ORDER/CALL NO.
3. DATE OF ORDER/CALL
(YYYYMMMDD)
4. REQUISITION/PURCH REQUEST NO. 5. PRIORITY
6. ISSUED BY CODE 7. ADMINISTERED BY (If other than 6) CODE 8. DELIVERY FOB
DESTINATION
OTHER
(See Schedule if
other)
10. DELIVER TO FOB POINT BY (Date)
(YYYYMMMDD)
12. DISCOUNT TERMS
13. MAIL INVOICES TO THE ADDRESS IN BLOCK
11. X IF BUSINESS IS
SMALL
SMALL DISAD-
VANTAGED
WOMEN-OWNED
CODE
15. PAYMENT WILL BE MADE BY
CODE
MARK ALL
PACKAGES AND
PAPERS WITH
IDENTIFICATION
NUMBERS IN
BLOCKS 1 AND 2.
16.
TYPE
OF
ORDER
DELIVERY/
CALL
PURCHASE
This delivery order/call is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract.
Reference your furnish the following on terms specified herein.
ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE
BEEN OR IS NOW MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME.
If this box is marked, supplier must sign Acceptance and return the following number of copies:
NAME OF CONTRACTOR SIGNATURE TYPED NAME AND TITLE DATE SIGNED
(YYYYMMMDD)
17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE
18. ITEM NO.
19. SCHEDULE OF SUPPLIES/SERVICES
20. QUANTITY
ORDERED/
ACCEPTED*
21.
UNIT
22. UNIT PRICE 23. AMOUNT
*If quantity accepted by the Government is
same as quantity ordered, indicate by X.
If different, enter actual quantity accepted below
quantity ordered and encircle.
24. UNITED STATES OF AMERICA
25. TOTAL
26.
DIFFERENCES
30. INITIALS
27a. QUANTITY IN COLUMN 20 HAS BEEN
INSPECTED RECEIVED
ACCEPTED, AND CONFORMS TO
THE CONTRACT EXCEPT AS NOTED:
c. DATE
(YYYYMMMDD)
b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE
28. SHIP. NO.
PARTIAL
FINAL
31. PAYMENT
COMPLETE
PARTIAL
FINAL
29. D.O. VOUCHER NO.
32. PAID BY
33. AMOUNT VERIFIED CORRECT FOR
34. CHECK NUMBER
35. BILL OF LADING NO.
42. S/R VOUCHER NO.
36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.
a. DATE
(YYYYMMMDD)
b. SIGNATURE AND TITLE OF CERTIFYING OFFICER
37. RECEIVED
AT
38. RECEIVED BY (Print) 39. DATE RECEIVED
(YYYYMMMDD)
40. TOTAL CON-
TAINERS
41. S/R ACCOUNT NUMBER
DD FORM 1155, DEC 2001
PREVIOUS EDITION IS OBSOLETE.
CONTRACTING/ORDERING OFFICER
9. CONTRACTOR CODE FACILITY
z
z
z
z
NAME
AND
ADDRESS
BY:
d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE
f. TELEPHONE NUMBER g. E-MAIL ADDRESS
